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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT �Q .fr C/ 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES.I .YEAR.FROM DATE ISSUED $ 4„f .(Complete in,Triplicate) w Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1$62 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 1�I.S Q�tL City7'�(Yrl�j�o”\. Lot Size PM_ Owner's Name C. X3(5 Address // f fete Phone ' N 1Q yo 3`7" , Contractor's Name�� - License No. - Phone Y62-lg2c/ TYPE OF WELL/PUMP: NEW WELL ❑ � ,�; WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP.INSTALLATION ❑ SYSTEM REPAIR .X° OTHER El DISTANCE TO NEAREST: SEPTIC TANK r f5EWELINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL; OTHER WELL — PITS/SUMPS INTENDED USE TYPE''-OF'WELL; PROBLEM AREA t CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom-t ❑ Manteca Dia. of Wall Excavation Dia. of Well Casing )� Domestic/Private 11 Gravel Pack El Tracy Type of Casing Specifications 11 Public Public Other ❑ Delta )Depth of famut Seal Type of Grout ❑ Irrigation _-�Approx-Depth Eastern-.4,-Surface Seal Installed by---�--� Repair Work Done Elt Type of Pump H.P.' State Work Done t4 `e. Well Destruction ❑ ! Well Diameter Sealing Material (top 50') . Depth ,Z P}O Fiiler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms , Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity-- No. Compartments PKG. TREATMENT PLT. ❑ f Method of Disposal J I Distance to nearest: Well. Foundation Property Line 1 LEACHING LINE . '❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest:. Well Foundation _ Property Line t � i SEEPAGE PITS ,. ❑ Depth Size Number r SUMPS ❑ Distance to nearest:' Well Foundation Property Line DISPOSAL PONDS .'_ ❑ F I hereby certify that I.l ave prepared this application and that the,work will be done in accordance with San Joaquin county ordinances, state.laws, and rules and regulations of the San Joaquin Local Health District. ,Home owner or licensed agent's signature certifies the following: 1 certify that in the performance of the work for which this permit is issued, l shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature - certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa-' tion laws of California." ; -The applican ust I for all require nsp tions. Complete drawing on r�eyerse side. • k Q Signed r Title: -to, - � t �'"` Data: FOR DEPART ENT USE ONLY Application Accepted by, Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 - f Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 l ' a s INFO 'AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT:NO: i l �� EH 14-26 01831 T � .�